In the two decades since the National Research Council (NRC) issued its 1993 report Understanding Child Abuse and Neglect, a new science of child abuse and neglect has been launched, yielding findings that delineate a serious public health problem. Fully 6 million children are involved in reports to child protective services, and many more cases go undetected. Nationally, about three-quarters of cases are classified as neglect, and the majority of reports involve children under the age of 5. Important findings on the consequences of child abuse and neglect reveal the problem is not confined to children and childhood; rather, the effects of child abuse and neglect cascade throughout the life course, with costly consequences for individuals, families, and society. These effects are seen in all aspects of human functioning, including physical and mental health, and in important arenas such as education, work, and social relationships. Addressing this public health problem will require an immediate, coordinated research response that is grounded in the complex environments and systems within which child abuse and neglect occurs and that has high-level federal support.
This study was conducted in response to a request from the Administration on Children, Youth and Families (ACYF) within the U.S. Department of Health and Human Services to update the research highlighted in the 1993 NRC report (see Appendix B for research recommendations from that report). ACYF asked that the updated report “provide recommendations for allocating existing research funds and also suggest funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.” Specifically, ACYF asked the expert committee appointed to undertake this study to
• build on a review of the literature and findings from the evaluation of research on child abuse and neglect;
• identify research that provides knowledge relevant to the programmatic, research, and policy fields;
• recommend research priorities for the next decade, including new areas of research that should be funded by public and private agencies; and
• identify areas that are no longer a priority for funding.
The Institute of Medicine (IOM) and the NRC within the National Academies appointed a committee with expertise across a broad array of disciplines associated with child abuse and neglect to carry out this study. The committee commissioned a number of background papers that summarized research findings and detailed research infrastructure needs in key areas of child abuse and neglect research. It held four face-to-face meetings, including two public sessions, and numerous conference calls to review the literature; discuss the current understanding of the extent, causes, and consequences of child abuse and neglect and the effectiveness of intervention programs; and deliberate on its findings, conclusions, and recommendations. The committee also held a workshop on “Research Issues in Child Abuse and Neglect” (IOM and NRC, 2012).
Publications on child abuse and neglect have increased more than threefold over the past two decades, documenting significant advances in the field. Among the findings reported are the following: (1) research on the consequences of child abuse and neglect has demonstrated that they are serious, long-lasting, and cumulative through adulthood; (2) the consequences include effects on the brain and other biological systems, as well as on behavior and psychosocial outcomes; and (3) rigorous research has been conducted on interventions to address the problem. Yet despite these gains in grasping the scope and scale of the problem, as well as identifying some general preventive approaches with proven effectiveness, much of the research evidence also underscores how much remains unknown. The causes of child abuse and neglect need to be understood with greater specificity if the problem is to be prevented and treated more effectively. Also needed is a better understanding of what appear to be significant declines in physical and sexual child abuse but not neglect; why children have differential sensitivity to abuse of similar severity; why some child victims respond to treatment and others do not; how different types of abuse impact a child’s developmental trajectory; and how culture, social stratification, and associated contextual factors affect the causes, consequences, prevention, and treatment of child abuse and neglect.
DESCRIBING THE PROBLEM
A critical step in devising effective responses to child abuse and neglect is reasonable agreement on the definition of the problem and its scope. A key definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C. § 5101 note).
At a minimum, any recent act or set of acts or failure to act on the part of a parent or caretaker, 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, enshrined in federal legislation, establishes the basis on which all states, as well as American Samoa, the Commonwealth of the Northern Mariana Islands, the Commonwealth of Puerto Rico, the District of Columbia, Guam, and the Virgin Islands, develop laws requiring certain professionals to report instances of child abuse or neglect to child protective service agencies.
While the CAPTA definition is a useful benchmark for describing what one looks for in determining instances of child abuse and neglect, child abuse and neglect are defined differently across the various purposes for which information on the problem is collected. Achieving clarity in the area of child abuse and neglect has therefore been a challenge. Legal definitions vary across states; researchers apply diverse standards in determining incidence and prevalence rates in clinical and population-based studies; and substantial obstacles challenge efforts to learn about children’s, especially young children’s, experiences with caregiver-inflicted abuse or neglect. As a result, the characteristics of the problem and determinations regarding its scope will differ depending on the data source used for analysis. This challenge is articulated in the 1993 NRC report and continues to impede a full understanding of the nature of the child abuse and neglect problem.
Despite this definitional challenge, data are available with which to estimate the scope, prevalence, and characteristics of child abuse and neglect across the United States. The National Child Abuse and Neglect Data System (NCANDS) is the official child abuse and neglect reporting system for cases referred to state child protection authorities. In fiscal year 2011, all states, the District of Columbia, and all territories contributed counts of the number of cases referred to child protective services, the case characteristics, and the case outcomes. Based on NCANDS data, about three-quarters of reported cases are classified as neglect, about 18 percent as physical abuse, and about 9 percent as sexual abuse (ACF, 2012). The specific rates vary among states but overall reflect the general pattern that a substantial majority of cases are neglect, with physical and sexual abuse
representing much smaller groups. The characteristics of the child victims of abuse and neglect show a gender breakdown that is approximately evenly split between males and females. The highest rates of child abuse and neglect occur among the very youngest children. Perpetrators are mainly parents (81 percent), 88 percent of whom are biological parents (ACF, 2012). Somewhat more than half of perpetrators are female. These same demographic characteristics also are reflected in other research that draws its samples from national incidence studies utilizing different data sources and methodologies.
While some discrepancies exist across data sources, strong evidence indicates that sexual abuse has declined substantially in the past two decades, and the balance of evidence favors a decline in physical abuse, especially the more common and less serious forms. There is no evidence that neglect is declining overall. However, states vary significantly as to whether neglect is increasing, decreasing, or remaining constant. These disparate trends and their causes currently are not well understood. Such understanding is essential to bring clarity to the phenomena of child abuse and neglect and to identify appropriate program and policy responses.
CAUSES
Theoretical models for child abuse and neglect have progressed as the field has matured. Yet hundreds of studies have reported an association or correlation between a variety of potential risk factors and child abuse or neglect without considering these models. Drawing on the work of Brofenbrenner (1979) and Belsky (1980), who identified interrelated but embedded factors that contribute to child abuse and neglect, these risk factors can be organized into individual-level, family, and contextual factors. Contextual factors represent the broader social systems that influence parental functioning, including macrosystem factors representing the social or cultural forces that contribute to and sustain abuse or neglect.
Parental substance abuse, history of child abuse or neglect, and depression appear to have the strongest support in the literature as risk factors for child abuse and neglect. There is also a robust body of knowledge about the role of stressful environments and the impact of poverty. Other candidate risk factors that have received at least some support in the literature for an association with child abuse and neglect include children having a disability, parental psychopathology, early childbearing, low socioeconomic status, and social beliefs about discipline and corporal punishment. Acknowledging that risk factors seldom occur in isolation, some studies have shown that the presence of multiple risk factors can dramatically increase the likelihood of child abuse and neglect. It is important to acknowledge, however, that all of these factors simply describe circumstances surrounding
elevated risk, but that none of these individual or contextual factors has been shown to “cause” child abuse and neglect. There is also a relative lack of understanding of why certain factors result in abuse or neglect in some situations but not others. Further, the complex interaction among multiple risk factors, especially in conjunction with protective factors and resilience, is not clearly understood.
The field’s limited knowledge of causal pathways is due mainly to the fact that research in child abuse and neglect has utilized primarily correlational designs and analyses, relying heavily on cross-sectional studies and retrospective self-reports. Research in the field needs to include models that test causal pathways using rigorous research designs and analyses. This work would ideally involve longitudinal studies starting before the birth of the target children to permit better controlled studies of who does and does not commit child abuse and neglect and under what cultural, social, and individual circumstances. Animal model studies can provide insight on issues difficult to address in human studies.
CONSEQUENCES
Abuse and neglect appear to influence the course of development by altering many elements of biological and psychological development; in other words, childhood abuse and neglect have a profound and often lasting impact that can encompass psychological and physical health, neurobiological development, relational skills, and risk behaviors. The timing of the abuse or neglect and its chronicity clearly matter for outcomes. In particular, the more often children experience abuse or neglect, the worse are the outcomes.
Across human and nonhuman primate studies, perturbations to the hypothalamic-pituitary-adrenal (HPA) “stress” system often are associated with abuse and neglect and with a range of mental and physical health problems. Abused and neglected children also show behavioral and emotional difficulties that are consistent with effects on the amygdala, a structure in the brain that is critically involved in emotion and associated with internalizing of problems, heightened anxiety, emotional reactivity, and deficits in emotional processing. A number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Specifically, children who experience abuse and neglect appear especially at risk for deficits in executive functioning that affect behavioral regulation. Abuse and neglect also increase children’s risk for experiencing academic problems.
The impact of abuse and neglect on relational skills likely operates at least partially through disorganized attachment to the caregiver, which in turn can be predictive of long-term problems. As a result of abusive or
neglectful responses from caregivers, children are at risk for failing to develop effective strategies for regulating emotions in interactions with others. Further, abused and neglected children, like children with a history of institutional care, have problematic peer relations at disproportionately high rates. Similarly, abuse and neglect have been associated with dissociation among preschool- and elementary-aged children, as well as among adults.
Long-term outcomes among adolescents and adults with a history of abuse and neglect include higher rates of alcohol abuse and alcoholism, as well as elevated rates of posttraumatic stress disorder, compared with those without a history of abuse and neglect. Additionally, experiences of abuse and neglect in childhood have a large effect on suicide attempts in adolescence and adulthood. Moreover, children who experience abuse and neglect are more likely to engage in sexual activity at earlier ages than comparison groups. Childhood sexual abuse especially has been associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors.
Regarding impacts on physical health outcomes, at their most extreme, abuse and neglect are associated with stunted growth. The rate of untreated illness and infection is high among abused and neglected children, as has been found consistently among children living with their birth parents, children placed in foster care, and adults years after their experience of abuse or neglect. In various studies, different forms of abuse and neglect also have been linked with increased body mass index and increased rates of obesity in childhood, adolescence, and adulthood.
THE CHILD WELFARE SYSTEM
Each year, more than 3 million referrals for child abuse and neglect are received that involve around 6 million individual children. Contrary to popular belief, most investigated reports of child abuse and neglect do not result in out-of-home placement; only about 20 percent of investigated cases lead to the removal of a child from his or her home. The risk of placement and length of stay in out-of-home care can vary considerably based on such factors as a child’s age and the family’s race, socioeconomic status, and state of residence. Family-based care—specifically regular foster family care and relative (kinship) care—has been emphasized as the preferred option for the placement of an abused or neglected child. There has also been a policy impetus to limit the number of placements per child. The clinical literature documents that instability in placement has negative effects on children with respect to insecure attachment, psychopathology, and other problematic outcomes.
Since 1993, policy, practice, and program initiatives to improve the public child welfare system—the institution charged with providing soci-
ety’s response to suspected cases of child abuse and neglect formally reported to authorities—have received significant attention. The child welfare system provides four main sets of services: child protection investigation, family-centered services and supports, foster care, and adoption.
Beyond specific federal legislation that has paved the way for practice reforms, states and localities have adopted a number of system-level reforms that at their outset most likely were intended to improve child and family outcomes. These reforms have included differential response, privatization of child welfare services, models of parent and family engagement, and the implementation of practice models. The strongest evidence to date is on the effects of differential response.
Differential response systems have been implemented in 21 states, the District of Columbia, and four tribes to offer multiple pathways for addressing the needs of children and families referred to child welfare services. In its simplest form, differential response entails screening child abuse and neglect reports and, based on level of risk and other criteria, referring cases to either an assessment or a traditional investigation pathway. Results of some evaluations indicate a positive impact of this approach with regard to maintenance of child safety, fewer removals from home, increased access to services, and family satisfaction.
The child welfare system currently faces systemic concerns relating to a lack of organizational capacity to carry out some of the many promising practice and intervention models that are being developed. Barriers to sufficient organizational capacity include issues related to reduced funding; high caseloads; staff who are poorly trained, especially in addressing the social and emotional needs of the children who come in contact with the child protection services system; limited staff supervision; and a culture that does not necessarily support autonomy, quality practice, and critical thinking. Although certain organizational change strategies have been found to be evidence based and effective for improving workforce retention in child welfare, more research is needed in this area, especially research linking practice outcomes and workforce issues. Research also is needed to examine effective strategies for bringing to bear the interdisciplinary knowledge necessary to carry out all the diverse functions of a child welfare agency. And child welfare agencies need to employ more effective quality improvement strategies.
EFFECTIVE INTERVENTIONS AND SERVICE DELIVERY SYSTEMS
Since the 1993 NRC report was issued, significant advances have occurred in the development, evaluation, and dissemination of model programs for preventing or treating various forms of child abuse and neglect. In addition to the public child protection and child welfare systems found
in all communities, a variety of treatment programs targeting victims and perpetrators of child abuse and neglect are offered through various mental health and social service agencies. Many communities also have access to primary and secondary prevention services designed to reduce the risk for child abuse or neglect among families experiencing difficulties. Among this growing array of service options, there is strong evidence for the efficacy of an increasing number of interventions.
In the treatment domain, trauma-focused cognitive behavioral therapy, a brief structured program based on well-established theory and treatment elements, has been tested extensively and found to be effective with children affected by abuse and other traumatic experiences. Equally important has been the successful application of a number of well-established parent management training programs to children and families involved in the child welfare system. Again, these are programs with well-established theory and large bodies of knowledge.
In terms of prevention services, strategies such as early home visiting targeting pregnant women and parents with newborns are well researched and have demonstrated meaningful improvements in mitigating the factors commonly associated with an elevated risk for poor parenting, including abuse and neglect. Promising prevention models also have been identified in other areas, including public awareness campaigns, parenting education programs, and professional practice reforms. In contrast to the reality in 1993, policy makers and practitioners have a much stronger pool of program candidates on which to draw in both remediating the impacts of abuse and neglect and reducing its incidence.
Research suggests that a degree of reciprocity exists between service models and their host agencies. In some instances, the rigor and quality of these innovations may alter the standards of practice throughout an agency, thereby improving the overall service delivery process and enhancing participant outcomes. In other cases, organizations that provide little incentive for staff to adopt new ideas or that reduce the dosage or duration of evidence-based models to accommodate their limited resources contribute to poor implementation and reduced impacts. Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of those agencies in which such models and approaches are embedded and to how these factors impact service implementation.
While research carried out since 1993 has generated much knowledge that can inform programs and policies, some notable gaps remain. These include understanding of the underlying reasons why some individuals and families fail to benefit from treatment and prevention programs; of how evidence-based practices and interventions are implemented, replicated, and sustained; of which service attributes are most essential to achieving
the desired impacts and for whom; and of costs for training and supervision, data monitoring, and monitoring of service delivery. Research also is lacking on the question of system reform and the infrastructure required to institutionalize and support such reform. Little research exists that can inform how best to improve interventions and agency performance in the areas of workforce development, data management, and system integration. While some preliminary research has been conducted in the area of system integration, it remains unclear which strategies are most effective in building a collaborative culture and a set of working relationships across public institutions and between these institutions and the community-based agencies that constitute the child abuse and neglect response system.
RESEARCH INFRASTRUCTURE
To be productive, high-quality scientific research requires a sophisticated infrastructure. This is particularly true for research that requires multiple fields, disciplines, methodologies, and levels of analysis to fully address key questions. Research on child abuse and neglect is especially complex, involving diverse independent service systems, multiple professions, ethical issues that are particularly complicated, and levels of outcome analysis ranging from the individual child to national statistics. Moreover, the building of a national research infrastructure designed to adequately address the problem of child abuse and neglect will require a dedicated and trained cadre of researchers with expertise that spans the many domains associated with research in this field and the supports necessary to sustain high-quality, methodologically sound research endeavors. Moreover, the ability of the research to achieve the goal of informing quality programming and policies will be limited if the research fails to address the complex role of culture and context in the causes, consequences, prevention, and treatment of child abuse and neglect, particularly given the increasing heterogeneity of U.S. families.
Research on child abuse and neglect entails a number of challenges. As noted, the problem cuts across a wide range of domains, such as child welfare, medicine, child development, and public health. Services must be evaluated in multiple areas, such as treatment, prevention, and policy. Moreover, children and families receiving services related to child abuse and neglect often are eligible to receive services from other systems, and diversity in the type, timing, and intensity of these additional services can be difficult to account for in research on the effects of child abuse and neglect interventions. Services designed to respond to the problem of child abuse and neglect also are provided through the many systems that interact with abused and neglected children and their families, and these systems often act independently of one another, with little or no coordination. Finally, co-
ordination of research in the field and opportunities for support have been fragmented and generally insufficient to develop and sustain the capacity for a national child abuse and neglect research enterprise.
The formation of child abuse and neglect research centers presents an important opportunity to develop and sustain a volume of high-quality interdisciplinary research on child abuse and neglect. University-affiliated child abuse and neglect research centers also provide opportunities to train and support a new generation of researchers to ensure the growth of the field.
POLICY
Since the 1993 NRC report was issued, numerous changes have been made to federal and state laws and policies designed to impact the incidence, reporting, and negative health and economic consequences of child abuse and neglect. At its core, the debate around the development of laws and policies to help prevent child abuse and neglect involves questions of public value. It also involves trade-offs entailed in laws and policies between public benefit and private interests. Research evaluating laws and policies on child abuse and neglect can make it possible to anticipate and respond to predictable problems that may occur as a result of their implementation. Research helps address questions whose answers are critical to implementing child protection laws and policies effectively.
The research design needed to evaluate laws and policies is not always the same as the design one would use for the evaluation of child abuse and neglect practice interventions. Although some laws and policies can be evaluated by random assignment (e.g., studying the differential response approach discussed above), random assignment cannot be used if it would differentially affect the legal rights of citizens, if it would subject citizens to unequal treatment under the law, or if it would place children in jeopardy. Furthermore, simply studying the incidence of child abuse and neglect in the aggregate (such as at the state or national level) is unlikely to aid in determining and attributing potential causes.
Another difficulty in evaluating laws and policies related to child abuse and neglect is that adherence to a law, such as one on mandatory reporting, often is predicated on public knowledge, understanding, and support, which frequently vary across practitioner disciplines, as well as within and among states. Finally, much of the evolution in child abuse and neglect law and policy over the last few decades has consisted of incremental changes to existing legislation (such as CAPTA). In these cases, what is needed is research on the implementation and augmentation of the law or policy rather than the core law or policy itself.
Given these complexities in conducting analyses of child abuse and
neglect laws and policies and the fact that the laws and policies vary by state, it is not surprising that little research has been done in this area. A number of federal laws set national standards for confronting child abuse and neglect issues; however, many standards are either further elucidated by or completely derived from state legislation. Research on changes in both state and federal laws and policies has been extremely limited.
The heterogeneity of state laws on child abuse and neglect can be viewed as offering the opportunity for a natural experiment. State variations in such areas as mandated reporters, definitions of abuse and neglect, and the range of penalties provide a myriad of opportunities to examine the impact of policy change. New methods, such as propensity scoring and difference-within-difference analyses, can be powerful tools for examining policy-relevant questions.
RECOMMENDATIONS
The committee formulated a set of recommendations around four pertinent areas, focused on the development of a coordinated research enterprise in child abuse and neglect that is relevant to the programs, policies, and practices that influence children and their caregivers. The four areas are (1) development of a national strategic research plan that is focused on priority topics identified by the committee and that delineates implementation and accountability steps across federal agencies (Recommendations 1-3), (2) creation of a national surveillance system (Recommendation 4), (3) development of the structures necessary to train cohorts of high-quality researchers to conduct child abuse and neglect research (Recommendations 5-7), and (4) creation of mechanisms for conducting policy-relevant research (Recommendations 8-9).
A National Strategic Research Plan
Recommendation 1: Federal agencies, in partnership with private foundations and academic institutions, should implement a research agenda designed to advance knowledge and understanding of the causes and consequences of child abuse and neglect, as well as the identification and implementation of effective services for its treatment and prevention. The research priorities listed in Figure S-1 should be considered in this agenda.
Recommendation 2: The Federal Interagency Work Group on Child Abuse and Neglect, under the auspices of the assistant secretary of the Administration for Children and Families, should develop a strategic plan that details a business plan, an implementation strategy, and de-
partmental accountability for the advancement of a national research agenda on child abuse and neglect.
Recommendation 3: The assistant secretary of the Administration for Children and Families should convene senior-level leadership of all federal agencies with a stake in child abuse and neglect research to discuss and assign accountability for the implementation of a strategic plan to advance a national research agenda on child abuse and neglect.
FIGURE S-1 Research priorities in child abuse and neglect.
A National Surveillance System
Recommendation 4: The Centers for Disease Control and Prevention, in partnership with the Federal Interagency Work Group on Child Abuse and Neglect, should develop and sustain a national surveillance system for child abuse and neglect that links data across multiple systems and sources.
Training of Researchers
Recommendation 5: Federal agencies, in partnership with private foundations and academic institutions, should invest in developing and sustaining a cadre of researchers who can examine issues of child abuse and neglect across multiple disciplines.
Recommendation 6: Federal agencies, in partnership with private foundations and academic institutions, should provide funding for new multidisciplinary education and research centers on child abuse and neglect in geographically diverse locations across the United States.
Recommendation 7: The National Institutes of Health should develop a new child maltreatment, trauma, and violence study section under the Risk, Prevention, and Health Behavior Integrated Review Group.
Mechanisms for Conducting Policy-Relevant Research
Recommendation 8: To ensure accountability and effectiveness and to encourage evidence-based policy making, Congress should include support in all new legislation related to child abuse and neglect, such as reauthorizations of the Child Abuse Prevention and Treatment Act, for evaluation of the impact of new child abuse and neglect laws and policies and require a review of the findings in reauthorization discussions.
Recommendation 9: To ensure accountability and effectiveness, to support evidence-based policy making, and to allow for exploration of the differential impact of various state laws and policies, state legislatures should include support in all new legislation related to child abuse and neglect for evaluation of the impact of new child abuse and neglect laws and policies and require a review of the findings in reauthorization discussions.
REFERENCES
ACF (Administration for Children and Families). 2012. Child maltreatment, 2011 report. Washington, DC: U.S. Deparment of Health and Human Services, ACF. http://www.acf.hhs.gov/sites/default/files/cb/cm11.pdf (accessed December 3, 2013).
Belsky, J. 1980. Child maltreatment: An ecological integration. American Psychologist 35(4): 320-335.
Bronfenbrenner, U. 1979. The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
IOM (Institute of Medicine) and NRC (National Research Council). 2012. Child maltreatment research, policy, and practice for the next decade: Workshop summary. Washington, DC: The National Academies Press.
NRC. 1993. Understanding child abuse and neglect. Washington, DC: National Academy Press.
