7


Research Challenges and Infrastructure

To be productive, high-quality scientific research requires a sophisticated infrastructure. This is especially true for research in which multiple fields, disciplines, methodologies, and levels of analysis are required 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. Coordinating these multiple layers and systems requires a cohesive response from the federal government, private foundations, and academic institutions. All of these entities work together to build a research enterprise that can address the preventable problems of child abuse and neglect, making it possible to better understand, intervene in, and evaluate the pathways from causes to consequences and improve children’s lives. This chapter describes the current landscape of research on child abuse and neglect, highlights the multiple challenges encountered in conducting such research, and considers opportunities for increasing and improving this research as a coordinated field. The final section presents conclusions.

COMPONENTS OF THE CHILD ABUSE AND
NEGLECT RESEARCH INFRASTRUCTURE

Several components must be in place if a research infrastructure that is both effective in the short term and sustainable over time is to be built. Box 7-1 lists the human and physical capital components of a scientific research infrastructure. Building the research infrastructure needed to sup-



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7 Research Challenges and Infrastructure T o be productive, high-quality scientific research requires a sophis- ticated infrastructure. This is especially true for research in which multiple fields, disciplines, methodologies, and levels of analysis are required to fully address key questions. Research on child abuse and neglect is especially complex, involving diverse independent service systems, mul- tiple professions, ethical issues that are particularly complicated, and levels of outcome analysis ranging from the individual child to national statistics. Coordinating these multiple layers and systems requires a cohesive response from the federal government, private foundations, and academic institu- tions. All of these entities work together to build a research enterprise that can address the preventable problems of child abuse and neglect, making it possible to better understand, intervene in, and evaluate the pathways from causes to consequences and improve children’s lives. This chapter describes the current landscape of research on child abuse and neglect, highlights the multiple challenges encountered in conducting such research, and considers opportunities for increasing and improving this research as a coordinated field. The final section presents conclusions. COMPONENTS OF THE CHILD ABUSE AND NEGLECT RESEARCH INFRASTRUCTURE Several components must be in place if a research infrastructure that is both effective in the short term and sustainable over time is to be built. Box 7-1 lists the human and physical capital components of a scientific research infrastructure. Building the research infrastructure needed to sup- 297

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298 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH BOX 7-1 Basic Infrastructure Requirements for Research on Child Abuse and Neglect Human Capital • Workforce o Professionals o Support staff • Training and mentoring o Funded researchers o Training funds o Competent mentors • Access to specialty consultation • Larger research community o Colleagues o Robust partnerships with agency-based and community collaborators o Representation in study sections and journal reviews o General consensus on methodology, priorities, and key problems o Results valued by policy makers and funders Physical Capital • Space o Clinical o Office o Administrative and support staff o Research • Basic instrumentation • Information technology Management and Capacity • Data management • Access to specialized instruments and services • Patient/participant recruitment and flow • Grant management and regulatory compliance •  apacity in service sectors working with children and families who experi- C ence child abuse and neglect to engage in and use research port and sustain a field of child abuse and neglect that can inform practices, programs, and policies requires a coordinated, comprehensive approach. The infrastructure should be designed to (1) incorporate multidisciplinary and multimethod perspectives in research design; (2) initiate research fo- cused on determining the role of cultural factors; (3) incorporate additional longitudinal data, improved surveillance mechanisms, and registries; (4) co- ordinate the allocation of sufficient research funding; and (5) develop a

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RESEARCH CHALLENGES AND INFRASTRUCTURE 299 robust workforce through training and mentorship. Each of these elements is examined in turn in this section. Multidisciplinary and Multimethod Perspectives Child abuse and neglect research encompasses a wide range of dis- ciplines and research problems. Figure 7-1 depicts 11 of the most salient domains identified by the committee: mental health, physical health, imple- mentation science, child development, policy research, neurobiology, court interventions, child welfare, public health, forensic sciences, and ethical issues. Under each domain are examples of the types of problems, missions, and tasks addressed by investigators, as well as key disciplines that may be engaged in this research. Each of these domains has unique research infra- structure needs, methodologies, and agendas. This list is not comprehensive, but provides a general overview of the breadth of disciplinary involvement in child abuse and neglect research. Selected domains are discussed below. These domains, as well as many others that relate to the study of child abuse and neglect, have specific focuses with respect to the causes and consequences of child abuse and neglect, as well as the delivery of services to prevent or treat its effects. However, the topics of interest specific to each research domain do not exist in isolation from the others. Integrating multidisciplinary perspectives into research across these domains can allow researchers to examine the many contextual factors surrounding incidents of abuse and neglect, to disentangle its consequences from the many co- occurring risk factors, to examine the many outcomes of interest from the implementation of programs and services, and to understand the interac- tions among services from the many providers that encounter abused and neglected children. Physical Health Published medical research on child abuse and neglect has addressed its epidemiology; its clinical manifestations and presentation, diagnosis, treatment, and outcomes; issues related to the medical care needs of foster children; and prevention. The clinical manifestations and nature of the histories presented have been published for many forms of child abuse ac- cording to discrete sets of conditions (e.g., abusive head trauma, physical abuse, sexual abuse). Attention has been paid to improving diagnoses and avoiding false-positive diagnoses, as well as improving assessments of both future risk and safety. Epidemiological data have been accumulating. One area of great interest is screening in medical practice, given that this is the first line of defense in many cases. Screening in medical practice is the process of looking for occult condi-

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Behavioral Science Parenting Interventions 300 Trauma Screening Injury Biomarkers Psychiatry, Psychology, Child Protection Services Therapy Informed Consent Biomechanics Prevention Science Program/Service Implementation Social Work Covert Surveillance Forensic Interviews Epidemiology Social Work Interventions Treatment Development Foster Care Mental Ethical Forensic Public Health Issues Sciences Health Child Welfare Physical Health Court Child Abuse and Interventions Pediatrics Neglect Research Compliance with Court Order Orthopedics Youth Participation Pathology Criminal Sanctions Radiology Judicial Decision Making Neurology/Neurosurgery Implementation Science Child Policy Dissemination of Evidence- Development Neurobiology Research Based Prevention Strategies Physical Mandated Reporting Dissemination of Evidence- Epigenetic Effects Based Treatments Social/Emotional Alternative Response Stress Response Systems Fidelity and Sustainability Cognitive Brain Development Research Influence of Parenting Approaches FIGURE 7-1  Child abuse and neglect research domains.

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RESEARCH CHALLENGES AND INFRASTRUCTURE 301 tions before they become manifest (Fletcher et al., 2005). The principles of screening include having a screening test that is acceptable with appropriate sensitivity and specificity, seeking an important condition, having effective interventions available, and seeing a better outcome if the condition is identified early rather than late (Fletcher et al., 2005). In 2004, the U.S. Pre- ventive Services Task Force (USPSTF) considered whether the evidence sup- ported recommending that physicians screen for child abuse and neglect in medical practice. The task force concluded: “We identified no studies meet- ing eligibility criteria that directly addressed the effectiveness of screening in a health care setting in reducing harm and premature death and disability, or the adverse effects of screening and interventions” (Nelson et al., 2004, p. 29). In January 2013, the USPSTF released a new systematic review ad- dressing the same question (Selph et al., 2013). Although this review still does not offer strong support for screening, it is somewhat more supportive based on the impact of multiple home visiting trials (Duggan et al., 2004; Kitzman et al., 1997; Olds et al., 1986, 2007) and a single study of screen- ing in pediatric primary care (Dubowitz et al., 2009). The task force states: “In conclusion, trials of risk assessment and behavioral interventions and counseling in pediatric clinics and early childhood home visitation pro- grams indicated reduced abuse and neglect outcomes for children, although all trials had limitations and trials of home visitation reported inconsistent results…. More research is needed in key areas to provide clinicians with effective methods of [identifying children at risk for abuse and neglect]” (Selph et al., 2013, p. 188). Thus the USPSTF has called for more research on screening for child abuse and neglect in medical practices. New work is needed to document the process of screening (including asking parents or children directly), the proportion of children that receive the interven- tion and the proportion of refusals to participate, the beneficial impact for children or parents, and any adverse impacts. Research on using the medical examination to detect abuse or neglect shows mixed results. For example, complete skeletal surveys have been recommended as an adjunct for assessing young injured children for physi- cal abuse; however, there are gaps in knowledge about when, with whom, and how often X-rays should be obtained, aside from issues of the accuracy of readings or the appropriate technology for imaging. Rib fractures and multiple fractures are known to be associated with abuse more commonly than other fractures in young children (Kemp et al., 2008), but questions remain about when a diagnosis of abuse should be considered and X-rays ordered in potentially related conditions such as acute life-threatening events, seizures, burns, and abusive head injury. Unanswered questions include: What are the clinical indications for performing a radiographic skeletal survey?, What are the yields of X-rays in different populations of children?, and What is the utility of follow-up X-rays where data suggest

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302 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH improved sensitivity and specificity at the expense of increased radiation and monetary costs? Research is needed to ascertain the most sensitive, specific, and cost-effective methods for identifying skeletal injuries, with consideration of the hazards of increased radiation exposure. Comparative studies of findings across clinical centers using standardized reporting could improve understanding of fracture mechanics and identification of abusive versus accidental injuries. With respect to sexual abuse, prior research has led the American Academy of Pediatrics (AAP) to publish interpretations of the relationship between some sexually transmitted infections and the likelihood of such abuse (Kellogg, 2005). However, many questions remain, such as: What is the specificity of ano-genital warts for a sexual abuse diagnosis in children?, How is this altered by the age and gender of the child, site of the lesions, or human papillomavirus type?, What is the natural history of this infection with vertical transmission or increasing age of the child?, What sensitivity and specificity do nucleic acid amplification tests have in detecting infection for the range of potential sexually transmitted infections?, Which diagnostic tests for sexually transmitted infections should be used for which parts of the body and at what time?, and What are the appropriate clinical indica- tions for these tests? Abusive head trauma was first described as shaken baby syndrome more than 40 years ago, yet intense public and legal controversy over this diagnosis persists. Several challenges are associated with the diagnosis. First, perhaps, is terminology and what is or is not included in this diagno- sis category. As absolute certainty is rare with abusive head trauma cases, and a probabilistic or Bayesian approach to the diagnosis is consistent with this uncertainty. Another controversy in studies of abusive head trauma has to do with the relationship between hypoxia in isolation and subdural hem- orrhage in infants. A clear characterization of the sensitivity and specificity of subdural hemorrhage, subarachnoid hemorrhage, and cervical epidural hemorrhage as markers for both neurotrauma and hypoxia/ischemia is lack- ing. The phenomena of scar retraction and spontaneous rebleed have been suggested as a challenge to determining the time of injury. Systematic study of subdural membranes and neuropathology related to rebleeds is needed to settle this controversy. Another area of controversy needing explication is the significance and location of beta amyloid precursor protein (APP) in the brain as a marker of trauma, hypoxia-ischemia, or infarction. Eye injuries, specifically retinal hemorrhages, have been interpreted as evidence of abusive head trauma by some and disputed by others.

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RESEARCH CHALLENGES AND INFRASTRUCTURE 303 Policy Research As discussed in Chapter 8, there have been numerous changes to federal and state laws and policies designed to impact the incidence, reporting, and negative health and economic consequences of child abuse and neglect since the 1993 National Research Council (NRC) report was issued. In addition, states vary widely in policies regarding mandated reporters; definitions of abuse and neglect; inclusion of witnessing intimate partner violence; and expansions of what is included in the laws, the range of penalties, and stipu- lations of such things as shaken baby prevention in the nursery. However, research examining the impact of policy changes and variations across state laws on outcomes for children and families, as well the systems responsible for implementing the policies, has been scant. Despite an increased federal focus on implementing evidence-based policies, support has been lacking for research efforts to evaluate policies related to child abuse and neglect. Child Welfare A number of new research opportunities are emerging in the child wel- fare field. Large administrative datasets now available can be analyzed to inform practice, as well as case-linked to other electronic records to permit multidimensional and longitudinal evaluations of outcomes. Child welfare providers and funders increasingly are required to employ evidence-based practices and thus are active consumers of research, as described in Chap- ter 6. Areas of research, including in many instances testing of interven- tions, include addressing child neglect, parent engagement, infant mental health, community-based prevention and parenting education, addressing trauma and meeting the mental health needs of children who experience abuse and neglect, risk and safety assessment, decision making, the impact of substance abuse on child abuse and neglect, links between child abuse and neglect prevention and economic well-being, achieving permanency through guardianship, reducing long-term foster care, and accountability and performance-based contracting. The social work profession provides a large part of this research community, and successful collaborations be- tween child welfare agencies and universities offer a range of examples of how to create productive research partnerships. Funding for research evaluating child welfare programs is potentially available through many discretionary programs advanced through the mul- tiple initiatives and priorities of the Children’s Bureau and its Office on Child Abuse and Neglect. Other potential funding sources are the Cen- ters for Disease Control and Prevention (CDC); the National Institutes of Health (NIH); the Department of Justice; and several foundations, in- cluding the Doris Duke Charitable Foundation and the William T. Grant

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304 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Foundation. Since the 1993 NRC report was issued, the Children’s Bureau has strengthened the rigor of the required evaluations. In addition, federal legislation—for example, Title IV-E waivers for demonstration projects— has required rigorous evaluation, and many demonstrations have included randomized designs. As noted in Chapter 5, however, the 2011 waiver au- thority stipulates that the review of applications for Title IV-E waivers for fiscal years (FYs) 2012-2014 cannot consider whether the applicants will use an experimental design, reducing the impetus for the use of random assignment in Title IV-E waiver demonstrations (Testa, 2012). Moreover, although there have been recent federal investments such as funding for training under Titles IV-E and IV-B, there have been no commensurate investments in child welfare research capacity. In fact, the small discretionary research program of the Children’s Bureau, which also included some funding for doctoral students, was terminated in 1996, when the funds were used to launch the National Study of Child and Adolescent Well-Being as part of the Personal Responsibility and Workforce Invest- ment Act. Unless potential investigators seeking support for field-initiated research approach NIH or CDC, there will be no national funding source for such research or for training for child welfare researchers. Given the few child welfare researchers being supported by these latter organizations, the number of mentors or reviewers for such research is limited, and there is little experience in the field with these funding sources. Public Health Child abuse and neglect is now recognized as a major public health problem by the World Health Organization and CDC (CDC, 2010, 2012a; Fang et al., 2012; Putnam-Hornstein et al., 2011; WHO, 2013). Research such as the seminal Adverse Childhood Experiences studies of Felitti and colleagues demonstrates the significant associations between childhood adversities and chronic medical conditions such as heart disease, diabetes, cancer, and obesity, as well as HIV risk (Anda et al., 1999, 2007; Chapman et al., 2004; Dong et al., 2003; Dube et al., 2001, 2003a,b; Felitti et al., 1998). The classic public health approach is often conceptualized as a four- step process (Putnam-Hornstein et al., 2011). The first step is the imple- mentation of a good surveillance system to collect and analyze data with which to detect and describe the condition, thereby informing the planning and implementation of public health interventions. The second step is the identification of risk and protective factors. The third is the development and testing of interventions focused on the identified risk and protective fac- tors. The fourth and final step is the implementation of effective prevention and control strategies. Steps three and four require an ongoing surveillance

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RESEARCH CHALLENGES AND INFRASTRUCTURE 305 infrastructure to evaluate the effectiveness of interventions and prevention strategies. Suggestions for improving surveillance of child abuse and neglect in- clude using data from multiple independent sources, linking cases across different databases, and enforcing the standard case definitions (Medina et al., 2012).1 Pilot efforts entailing each of these strategies have yielded im- provements in surveillance (Medina et al., 2012; Putnam-Hornstein et al., 2011; Schnitzer et al., 2004). Because abused and neglected children come in contact with multiple systems (e.g., health care, social services, educa- tion, law enforcement, and child death reviews), aggregating data across multiple independent sources can improve the identification of cases not re- ferred to child welfare agencies. Linking case-based data from two or more datasets has proven especially informative about risk factors. In California, linking birth certificate data with child protection records for more than 2 million children aged 5 and younger enabled the identification of variables associated with high rates of child abuse and neglect (Putnam-Hornstein et al., 2011). The study found, for example, that 1 of every 3 children born without established paternity were reported to child protective services for abuse and neglect; about 1 in 10 children born to teenage mothers were victims of abuse and neglect. Case-linkage studies are proving important for the early identification of groups that are at highest risk and therefore most likely to benefit from public health interventions. Case-linkage methodology requires quality datasets and sophisticated data management expertise to merge informa- tion reliably. Open-source software (e.g., Link Plus, developed by CDC) is increasingly available, as are standards for evaluating the probability of case matching. For research purposes, there are methodological and practi- cal advantages to linking administrative data across systems. As noted by Jonson-Reid and Drake (2008), such linkage mitigates the underreporting biases found when single-agency data sources are used to understand im- mediate and longer-term outcomes. Analysis of administrative data in con- junction with survey data offsets the limitations of retrospective accounts of victimization based on respondent recall (Brown et al., 1998; Widom et al., 2004) and the use of resource-intensive, prospective in-person sampling methods (Dubowitz et al., 2006). For the field of child maltreatment, such analysis allows for greater research, practice, and policy synthesis (Drake and Jonson-Reid, 1999) and the examination of risk factors, recurrence or 1  The term surveillance is used here in the public health sense to refer to a systematic assess- ment of the extent and nature of the child abuse and neglect problem by counting children or cases in a way that makes it possible to know the rates of occurrence; assess trends in types of abuse or neglect; and understand relationships to other important variables, such as single parenthood, special populations, and child gender and age.

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306 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH recidivism, and prevention and intervention outcomes (Jonson-Reid and Drake, 2008; Medina et al., 2012). Children and families presenting with comorbid problems are involved with multiple systems, including the medi- cal, child welfare, early childhood, juvenile justice, legal and judicial, and public health systems, as well as community-based services. While emphasis has increased on coordination across child protection and local service de- livery environments (e.g., one-stop approaches, systems of care, interoper- ability2) and on the use of data-driven decision making, the case record of a child’s or family’s contact, referral, and service receipt over time is often distributed across administrative datasets housed in different institutional settings (Jonson-Reid and Drake, 2008). Although most child abuse and neglect agencies lack the in-house ex- pertise to benefit from using multiple data sources or case linking across datasets, efforts are being made to build this capacity. In response to this need, for example, Chapin Hall at the University of Chicago instituted Ad- ministrative Data Institutes for child welfare managers in the early 1990s. To foster the integration of research with policy and practice, Chapin Hall has since 2007 offered annual sessions in Advanced Analytics for Child Welfare Administration, which focus on using longitudinal administrative data in child welfare decision making, program planning, and outcome monitoring (Chapin Hall, 2012). A timely, sensitive, and reliable surveil- lance system also is necessary to determine the effectiveness of child abuse and neglect prevention programs. A coordinated national public health approach to child abuse and neglect will not be possible without a mod- ern, general population-based, epidemiological surveillance system. The enormous costs and lifelong consequences of child abuse and neglect call for investment in a surveillance infrastructure commensurate with the mag- nitude of the problem. Ethical Issues Abused and neglected children and adolescents are a vulnerable popu- lation (MacMillan et al., 2007). As a result, ethical issues raised by pro- posed research in the field receive intensive scrutiny from study sections and institutional review boards. Questions often raised include: (1) Who is authorized to provide informed consent when children are wards of child protection?; (2) Under what circumstances can adolescents provide 2  Findings from the pilot Information Portability Project indicate that the use of mobile technologies and the sharing of information across child- and family-serving systems facilitates access to information in real time, making it possible to monitor safety and well-being, coordi- nate service delivery, promote data-informed decision making, and reduce service duplication (Schilling-Wolfe, 2010).

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RESEARCH CHALLENGES AND INFRASTRUCTURE 307 informed consent?; (3) Is it harmful to ask subjects about possible abuse and neglect experiences, and at what age is this permissible?; (4) How does mandated reporting affect research confidentiality?; (5) Are researchers required to provide treatment or services when they uncover abuse and neglect?; (6) What inducements to participate in research are appropri- ate and not coercive for children or families involved in child protection investigations?; and (7) What are ethical approaches to tracking subjects involved in longitudinal studies? (MacMillan et al., 2007). Box 7-2 presents an example of difficulties faced by child abuse and neglect researchers as a result of ethical concerns of institutional review boards. The Role of Cultural Factors There is a continuing need to understand the complex role of culture and context in the causes, consequences, prevention, and treatment of child abuse and neglect (Feiring and Zielinski, 2011), particularly in light of the increasing heterogeneity of U.S. families (IOM and NRC, 2011). Viewing culture as shared and dynamic (Korbin, 2002), focused on the learning and transmission of behavior and activity and the expression of internalized norms and models (Rogoff, 2003; Weisner, 2002), provides a lens for the examination of risk and protective factors for child abuse and neglect within families, neighborhoods, and communities. Examples of cultural factors relevant to child abuse and neglect and child well-being that have been examined across research disciplines include child-rearing practices (Earle and Cross, 2001; Ferrari, 2002; Waters and Sykes, 2009), fathers’ parenting behaviors (Ferrari, 2002), adultification of young chil- dren (Burton, 2007), child care burdens (Roditti, 2005), perceptions of neglect (Evans-­ ampbell, 2008), sibling caretaking and self-care among C children of immigrants (Greene et al., 2011; Hafford, 2010), expressions of familism3 and the role of extended families in systems of parental authority and disciplinary practices (Fontes, 2002; Fuhua and Qin, 2009), and family cohesion and mutual aid (Fuhua and Qin, 2009). Context, place, and struc- tural factors, including poverty and historical trauma, also interact with culture and family dynamics (Coulton et al., 2007; DeBruyn et al., 2001). Understanding cultural factors related to risk and protective factors for child abuse and neglect or the effectiveness of interventions requires the complementary use of qualitative and quantitative research methodologies (Korbin and Spilsbury, 1999). Understanding the interplay of micro- and macro-level processes and establishing the evidence base also entails the use of methods and approaches that are culturally sensitive and responsive to 3  Attitudes, behaviors, and family structures operating within an extended family system (Germán et al., 2009).

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338 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH BOX 7-3 Pediatric Acquired Brain Injury Centers A proposal currently being considered in Congress would establish 50 state Pediatric Acquired Brain Injury Centers. These centers would support clinical care, rehabilitation services, prevention activities, and research for brain injuries in children, including those related to both child abuse and sports, as well as un- intentional injuries from other sources. It is too early to know whether this proposal will succeed. It follows in the footsteps of an earlier proposal in the early 2000s, supported by the American Academy of Pediatrics, to develop a number of child abuse centers in academic medical centers. That proposal, to form Health Child Abuse Research and Evaluation Centers, never received support from any federal agency or Congress and did not move forward. BOX 7-4 The Early Experience, Stress, and Neurodevelopment Center The Early Experience, Stress, and Neurodevelopment Center is an example of an effective multidisciplinary infrastructure for translational research on child abuse and neglect and for training for a new generation of translational research- ers. The center had its origins in a 1998 call for proposals from the National In- stitute of Mental Health. The center was initially directed by Megan Gunnar, who studies stress and human development, and Paul Plotsky, who studies early-life stress in rodent models. The project period for the mature center, with Direc- tor Megan Gunnar and Associate Director Philip Fisher, runs from March 2009 through February 2014. The center has 14 faculty members representing nine universities and re- search centers and brings to bear a range of expertise critical to understanding the impact of early-life stress on neurobehavioral development. The center’s staff includes researchers who work predominantly with animal models, both rodent and nonhuman primate, as well as researchers studying human development. Their areas of expertise range from basic neuroscience to developmental psy- chopathology and prevention science. The center integrates basic developmental behavioral neuroscience research using nonhuman primate and human models to increase understanding of the behavioral and neurobiological impacts of early-life stress and to identify care experiences that support recovery. Preventive inter- vention researchers guide the center’s research so that future interventions can benefit from this more comprehensive knowledge base. Over 14 years, this center has been influential in advancing the field toward a more integrated understanding of the developmental sequalae of neglect and

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RESEARCH CHALLENGES AND INFRASTRUCTURE 339 outcomes; identification of disparities in system contact; mapping of client access to services and treatment; and planning initiatives in response to risk factors and needs (McEwen et al., 2011). Box 7-3 describes a current proposal for state Pediatric Acquired Brain Injury Centers. Box 7-4 describes the Early Experience, Stress, and Neuro- development Center. Finding: Various interdisciplinary collaborations focused on the deliv- ery of child abuse and neglect services, such as those found in CACs, the state CIP, and national traumatic stress networks, have improved coordination of services and can serve as venues for interdisciplinary research. Research collaboratives, such as ad hoc child abuse and ne- glect research networks and various privately supported child abuse and neglect research centers, serve as a model for support of the multi- disciplinary research necessary to advance the field of child abuse and neglect research. abuse. It has faciliated communication between scientists conducting basic re- search and those focused on the application of that work to preventive interven- tions for young children and their families. The structure of the center is depicted below. Methods used by the center include behavioral observations, electrophysiology (e.g., electroencephalogram), observation of neuroendocrine activity (hypothalamic-pituitary-adrenal axis) under basal conditions and in response to psychological and pharmacological chal- lenges, in vivo neuroimaging (magnetic resonance imaging, diffusion tensor imag- ing, magnetic resonance spectroscopy), and neurobehavioral tasks of amygdala and prefrontal functioning. Early Experience, Stress, and Neurobehavioral Development Center Behavioral Neurobehavioral/ Assay Data Management Coding Core Electrophysiology Core Core Core Project 1 Project 2 Project 3 Foster Care Postinstitutionalized Rhesus Infant Toddlers Children Studies NOTE: Administrative Core not shown.

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340 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH CONCLUSIONS Child abuse and neglect research is fraught with complexities. Re- search in the field involves diverse independent service systems, a number of related research domains, multiple professions, ethical issues that are particularly complicated, and levels of outcome analysis ranging from the individual child to national statistics. It has been difficult to establish uniform definitions and measures for all types of child abuse and neglect, mainly because of the diversity of research disciplines involved and the varying sources from which data are drawn. Researchers also must ac- count for a myriad of co-occurring risk and protective factors in drawing conclusions about the causes or consequences of child abuse and neglect. In addition, children and families receiving services related to child abuse and neglect often are eligible to receive services from other service systems. This can pose problems for researchers as diversity in the type, timing, and intensity of such additional services can be difficult to account for in study- ing the effects of child abuse and neglect interventions. Further, a number of potentially important cross-disciplinary outcomes may be impacted by intervention research. These challenges highlight the need for a sophisticated, multidisci- plinary research infrastructure. Despite notable efforts to support child abuse and neglect research by a number of public and private sources, significant components of the field’s infrastructure remain inadequately de- veloped. Future efforts need to focus on recruiting and training a dedicated and capable cadre of researchers, securing stable sources of research fund- ing, and developing sufficient physical capital to conduct research based on sophisticated designs. Also needed are interdisciplinary collaboration and the integration of cross-disciplinary methodologies and measures to yield more robust study designs. There remains a need as well for a nationally coordinated investment in the types of research necessary to advance the field. No one federal agency provides oversight of child abuse and neglect research investments. A high-level federal mechanism to coordinate and track all federally funded research on child abuse and neglect is needed. A high-quality population-based epidemiological surveillance system that draws on multiple data sources is critically necessary for the devel- opment of a national strategic approach to child abuse and neglect. The capacity to support more universal application of data linkage efforts among the many sources of child abuse and neglect information needs to be developed. Continued federal investment in nationally representative longitudinal studies, quality improvements in administrative data, and the timely dissemination of public-use data files are essential for understanding how the type, timing, extent, and chronicity of abuse and neglect affect chil- dren’s and adolescents’ psychosocial and behavioral development and for

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RESEARCH CHALLENGES AND INFRASTRUCTURE 341 developing population- and community-level practice and policy responses to prevent and ameliorate abuse and neglect. Further, research needs to be conducted with the appropriate methodological sensitivity to adequately analyze the impact of culture and other social factors that may inform the causal pathways of child abuse and neglect, particularly for marginalized and/or underresearched populations. Finally, the formation of child abuse and neglect research centers presents an important opportunity not only to develop and sustain a volume of high- quality interdisciplinary research related to child abuse and neglect but also to train and support a new generation of child abuse and neglect researchers to ensure the growth of the field. REFERENCES Amsel, L. V., N. Hunter, S. Kim, K. E. Fodor, and J. C. Markowitz. 2012. Does a study focused on trauma encourage patients with psychotic symptoms to seek treatment? Psychiatric Services 63(4):386-389. Anda, R. F., J. B. Croft, V. J. Felitti, D. Nordenberg, W. H. Giles, D. F. Williamson, and G. A. Giovino. 1999. Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association 282(17):1652-1658. Anda, R. F., D. W. Brown, V. J. Felitti, J. D. Bremner, S. R. Dube, and W. H. Giles. 2007. Ad- verse childhood experiences and prescribed psychotropic medications in adults. American Journal of Preventive Medicine 32(5):389-394. Anguksuar, L., Yup’ik, S. Jacobs, W. Thomas, and S. Lang. 1997. A postcolonial perspective on western [mis] conceptions of the cosmos and the restoration of indigenous taxono- mies. Two-Spirit People: Native American Gender Identity, Sexuality, and Spirituality 217-222. Appleyard, K., B. Egeland, M. H. M. van Dulmen, and L. Alan Sroufe. 2005. When more is not better: The role of cumulative risk in child behavior outcomes. Journal of Child Psychology and Psychiatry 46(3):235-245. Balsam, K. F., B. Huang, K. C. Fieland, J. M. Simoni, and K. L. Walters. 2004. Culture, trauma, and wellness: A comparison of heterosexual and lesbian, gay, bisexual, and two- spirit Native Americans. Cultural Diversity and Ethnic Minority Psychology 10(3):287. Barrera, M., F. G. Castro, and L. K. Steiker. 2011. A critical analysis of approaches to the development of preventive interventions for subcultural groups. American Journal of Community Psychology 48(3-4):439-454. Baum, K., K. M. Blakeslee, J. Lloyd, and A. Petrosino. 2013. Violence prevention: Moving from evidence to implementation. http://www.iom.edu/Global/Perspectives/2013/Violence PreventionImplementation.aspx (accessed November 26, 2013). Best, R. K. 2012. Disease politicis and medical research funding: Three ways advocay. Ameri- can Sociological Review 77(5):780-803. Block, R. W., and V. J. Palusci. 2006. Child abuse pediatrics: A new pediatric subspecialty. Journal of Pediatrics 148(6):711-712. Bonner, B. L., S. M. Crow, and L. D. Hensley. 1997. State efforts to identify maltreated chil- dren with disabilities: A follow-up study. Child Maltreatment 2(1):52-60. Brown, J., P. Cohen, J. G. Johnson, and S. Salzinger. 1998. A longitudinal analysis of risk fac- tors for child maltreatment: Findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse & Neglect 22(11):1065-1078.

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